Tactical tourniquet use – Part two

Ed Note: In part one of this two part series, which we suggest you read by clicking here, author Chuck Soltys explored self/buddy care, gear placement, basic hemorrhage control, as well as a few of the vital arteries and nerves in the leg. In part two below, Chuck looks at the types of tourniquets as well as the best practices for their use.

The tactical situation or the presence of an existing hostile threat may not allow the time and may prevent conventional methods of hemorrhage control such as direct pressure, elevation, and/or the use of a hemostatic agent. The recommended means to control extremity bleeding in a tactical environment while under fire is a rapidly and properly applied tourniquet.

If the casualty is shot in the head, neck, or torso, it is a load-and-go situation and medical care should be administered while enroute to a trauma hospital. If bullets or knives penetrate an arm or leg, these wounds are almost always survivable if a tourniquet is used immediately (delayed only by the officer first neutralizing the immediate threats). Once the bleeding is stopped, it is generally not a huge emergency. The officer can remain behind cover until the extraction route has been tactically cleared. Simply leave the tourniquet in place until arrival at the hospital.

In any typical domestic law enforcement situation, if arrival at a hospital cannot be accomplished within two hours, there was something drastically wrong with the plan. Wilderness operations and military operations may be an exception to this. Dr. John Wipfler, tactical and emergency physician, puts it thusly:

“When shot or stabbed in the arm or leg, it's simple...neutralize all known threats or until you are in a safe place, and then apply a tourniquet immediately. If you have a medic or fellow officer who wants to first try (for 20 - 30 seconds) to apply direct pressure / compressive dressing, that's fine. If you are by yourself, apply a tourniquet pronto.”

The use of tourniquets has long been discouraged by traditional EMS protocols. However, direct pressure is difficult to maintain during casualty extraction or transport under fire. As combat changes, so do our methods of treatment. In tactical medicine (TEMS), the training and use of tourniquets is not only accepted, it has become the standard intervention for life threatening bleeding injuries to extremities where time or situation are not conducive to the use of direct pressure methods. Tourniquet use is the most reasonable initial choice to stop extremity bleeding as you initiate care to yourself or someone else while under fire. Tourniquets should be immediately available to every officer on the street and should be part of the standard gear load-out for all SWAT operators.

Training in the proper use of a tourniquet is crucial. Generally speaking, a tourniquet will more likely be required for arterial bleeding rather than for venous bleeding. Arterial blood is oxygenated blood being pumped from the heart and is characterized by bright red blood spurting from the wound. Venous blood is deoxygenated blood that is returning to the heart and is characterized by a steady flow of dark red blood from the wound. The military cites several issues from the front lines regarding the use of tourniquets.

• Tourniquets are not being placed correctly
• Too liberal use of tourniquets on small oozing distal wounds
• Tourniquets are not being tightened enough

Types of Tourniquets1. Manufactured: There are a variety of well designed and manufactured tactical tourniquets currently on the market. In order to be a viable tourniquet for use in the tactical environment, the tourniquet must possess the following qualities (in no particular order):

• Easy to use. Can be applied one-handed
• Durable enough so that sufficient tension to occlude bleeding can be applied
• At least 1” wide
• Large enough to fit most upper legs
• Lightweight and compact
• Cost effective (since it is considered a disposable item)

The only tactical tourniquets currently approved for military issue are the Special Operations Forces Tactical Tourniquet (SOFTT) ™ (www.tacmedsolutions.com) and the Combat Application Tourniquet (CAT) ™ (www.combattourniquet.com).

2. Improvised: The windlass/cravat is an improvised tourniquet made by using a length of 1” or wider strap, webbing, or folded cravat and stick, tool, etc. to use as a windlass to apply sufficient tension. Using anything less than 1” wide for a tourniquet could substantially increase the risk of nerve damage to the victim and possibly result in permanent injury. However, life is more important than limb. If all that is available to use is something less than 1” wide and the blood flow is life-threatening; you must use what you have at your disposal. When improvising a tourniquet, you are only limited by your imagination. Items such as belts, rifle slings, or T-Shirts are just a couple of examples of items that most people would have with them and could be configured into an effective tourniquet. A tree branch, tool, or handcuffs are examples of items that could be used as a windlass. According to former operator and renowned trainer, Henk Iverson, who is currently training U.S. military troops, using the Israeli Battle Dressing as a "tourniquet" works well if applied properly. You may need to substitute a more durable object for the windlass in place of the plastic clip supplied with the bandage. It does take practice, especially if your hands are covered in blood. Training on making and applying an improvised tourniquet will be beneficial should you ever have to do it for real.

Facts about Tourniquets
• Damage to an arm or leg is rare if/when a tourniquet that is 1-2 inches in width is properly applied. Tourniquets may be left in place for 2-4 hours without difficulty, even up to 6 hours in some cases
• Tourniquets are often left in place for several hours during surgical procedures
• In the face of massive extremity hemorrhage, it is better to accept the small risk of damage to the limb than to have a casualty bleed to death
• A properly applied tourniquet is extremely painful. In fact, it will often be more painful than the actual gunshot or knife wound itself, and it will be significantly painful and function of the limb will be reduced until the tourniquet is removed. When a tourniquet is tightened sufficiently to occlude arterial flow, the muscles under the tourniquet can no longer contract, (or if they do, muscle damage or tearing can result)

Common Errors with Tourniquet Use
• Not using a tourniquet when you should
• Using a tourniquet when you shouldn’t
• Applying the tourniquet too high above the wound
• Not removing the tourniquet when you could (this should be left to experienced medical personnel in a medical facility)
• Not applying the tourniquet tight enough to stop hemorrhage

Tourniquet Application
Proper and immediate application of a tourniquet is critical since it takes about 2-4 minutes to bleed to death from a complete femoral artery and vein disruption.

• Apply without delay for life-threatening bleeding
• All gear and clothing should be removed from the wound site prior to applying the tourniquet
• Apply 2-3 inches above bleeding site
• Windlass should be placed directly over anatomical location of injured artery
• Tighten it until bleeding stops. A quick check of the radial pulse (in wrist area) or foot (top of foot or behind the inside ankle bone) to make sure the pulse is gone may be worthwhile when time allows
• Note time of application (with marker on forehead)
• Periodically check to ensure bleeding has not resumed

It is very important for all tactical operators and medics to practice repeatedly until the application of a tourniquet can be done confidently and rapidly within 30 seconds, with either hand (using only one hand) when applying a tourniquet on their own leg or arm.

Tourniquet Removal
• If at all possible, tourniquet removal should be left to experienced medical personnel in a medical facility
• For extended transport times (i.e. delay of more than 2-4 hours in getting casualty to a hospital), if the decision is made to loosen or remove the tourniquet, a properly placed compressive dressing, with or without hemostatic agents, should be put in place before the tourniquet is loosened. After releasing tourniquet, if significant bleeding through the dressing occurs, properly re-tighten the tourniquet
• When removing the tourniquet, loosen slowly and leave it in place
• Do not remove if there is no distal extremity
• If CASEVAC (casualty evacuation) is 2 hours or less, tourniquet should not be removed

Remember, if unable to control bleeding except with a tourniquet, it is better to sacrifice a limb than to lose a life to excessive bleeding.

Conclusion
Considering the threats faced by the police and military, it is no longer acceptable to report for duty only having attended a basic first aid class. This type of training is fine for a Boy Scout seeking a merit badge, but the police and military must not only be prepared and equipped to deal with a life threatening injury to themselves and/or their buddies, they must also be prepared to accept the responsibility of sustaining that emergency medical treatment until the casualty can be relinquished to a more definitive medical provider.

If your employing agency does not or will not provide you with the necessary emergency medical training and equipment, you must obtain it on your own. Everyone owes a certain amount of their own time and money to their chosen profession. While you may be right that this is the responsibility of your employer, don’t be dead right!